Therapeutic
Bottle Feeding
By Jessica Altemara
There are many reasons that most babies in the US receive bottles. Some parents are nursing from the breast and give bottles to supplement, due to feeding issues, low supply, or just out of preference. Some only give bottles while away from their baby, such as while at work or baby-less social occasions. Some parents are exclusively pumping or formula feeding, out of choice or necessity, and feed their babies entirely with bottles. For some families bottles are a preference and for some families bottles are a need.
Every parent wants to nurture and nourish their baby from a place of love, and with a commitment to meet their needs. As it is true that no bottle can fully replicate the experience of latching to and removing milk from a breast, the breast vs bottle debate does become heated and emotional.
This is not about that. This is about considering the ways that bottle feeding can be done that mirrors direct breastfeeding, so as to provide the maximum therapeutic value to bottle feeding. This is about leveling the playing field between breast and bottle, a bit, by combining breastfeeding behaviors with bottle feeding, for Best Bottle Feeding Practices. Here are “benefits” that are associated with feeding at the breast that can be replicated with mindful bottle feeding.
Feed on cue
Parents who are nursing from the breast are more likely to feed on cue, as opposed to implementing a schedule. Feeding on cue is associated with lower rates of childhood obesity because babies learn to listen to their own bodies, from the beginning, and are less likely to eat when they’re not hungry -or wait to eat until they’re “hangry,” and then gorge themselves.
Babies fed on cue may be a little older before they sleep for 8-12 hours without feeding, but they do eventually sleep independently, and this more frequent waking in the first 4 months actually reduces the risk of SIDS.
Feeding on cue is helped with some “hacks,” like a speedy bottle warmer, or a day’s worth of bottles prepped in the fridge for quick warming. Feeding on cue does also allow for offering a feed, should that be helpful if there are other needs to balance, like leaving the house, bedtime, or mealtimes for other family members. The primary aspect of feeding on cue is catching early signs of hunger and striving to begin a feeding before crying -a late sign of hunger- kicks in.
Use a nipple that is soft, long, anti-chomp, and a traditional shape
Many bottles claim to be “like the breast” by having a wide and round shape to them. It is true that this will usually cause lips to flange in a way that looks like a baby at the breast from the outside. However, these bottles do not feel, inside, a baby’s mouth the way a human nipple does.
Having a bottle nipple that causes a baby to engage inside their mouth in a way that is breast-like is more important. It means that babies are using more of the same muscles and this helps optimize oral development. In an optimal latch at the breast, a baby cups the nipple with their tongue and draws the nipple deeply into their mouth, virtually to the junction of the hard and soft palate. This is further back than many wide nipples go. By choosing a longer nipple, that goes further back, babies are less likely to have a gag reflex that is too sensitive, and struggle with processing solids. This also engages more of the tongue muscle, for better development.
Human nipples are also soft, which means they require more “holding on” than firmer bottle nipples do. When inside a baby’s mouth, human nipples compress and stretch so that the transition between breast and nipple is a gentle slope, unlike many bottles that have a sharp angle where the nipple meets the base. The human nipple slope engages the jaw and lip muscles differently and helps with good facial development. That is why it’s important to choose a nipple that is not too firm and has a traditional slope to it.
The other, important, aspect is to make sure that the nipple does not reward chomping. To test this, put some water in the bottle then hold the bottle parallel with the ground. While holding it so that the nipple has water in it, squeeze the nipple. If water comes spraying out, it rewards chomping. If there are just small drips, it is an anti-chomp nipple. By having a soft nipple that does not reward chomping, a baby will learn to hold on and integrate chewing reflexes later, in the right timing. While it doesn’t align with the marketing that many bottle manufacturers have utilized, the most basic nipple is, in many ways, more like breastfeeding than most of the fancy “breast like” options.
It is incredibly important that parents have grace with themselves about which aspects will be a good fit for their family -and which will not. The nurturing act of feeding a baby has so much potential. It can be something that is a form of connection and developmental support for the entire first year, regardless of the delivery system.
Hold baby in a nursing position for all feedings
While feeding is often a baby’s first social engagement, as babies get older, they are more and more interested in the world around them. If they can look around while eating, they are more likely to do so -and may overfeed.
Chronic overfeeding increases the rate of childhood obesity. Nursing directly is, frankly, boring. Babies are stuck facing their parent and can’t look around or hold the breast themselves. Bottle mobility is one of the biggest things that is connected with stomachs being stretched out and a tendency to overfeed through life. By always holding a baby for feedings and the parent always holding the bottle so that the baby has to face inward, feedings remain social instead of utilitarian. This means babies are also more likely to make eye contact regularly, which strengthens social skills. It also means that skin to skin and physical connection are built in, which is good for sensory development, laying down a foundation of being better regulated, for life.
For the most part, this looks like baby sitting on one leg and coming across to have their head rest on the opposite arm. It’s about figuring out how their body fits on their parent’s body. Tummy to tummy works for bottles too!
Use paced feeding
The other aspect of positioning for feeding is the actual bottle’s position. Paced feeding allows a baby to eat at a pace more similar to how they would at the breast. It lets them move between nutritive and non-nutritive sucking without continuing to drink much during non-nutritive sucking. It also allows them to understand that removing the milk from the bottle is their job.
Being active and engaged in the feeding process calls on babies to be connected to the experience. Not only does it reduce overfeeding, paced feeding has also been shown to reduce the amount of air babies swallow because they gulp less. The most important part of paced feeding is to make sure the nipple is only half full by holding the bottle mostly parallel to the ground. Stopping after 2-3 ounces (and at 5 ounces, for older babies), to offer a pacifier is also recommended. Additionally, it helps to hold the nipple in front of the baby’s nose and allow them to latch onto it, so that they are active in that process too.
For Best Feeding, the bottle can be held parallel to the floor and at about breast level, against the body. This provides the half-full nipple, baby-led latching, and nursing-similar position that combines everything mentioned so far. Keeping the nipple very slow flow is also wise. A preemie level or level 1 is usually as fast a nipple as is ever needed. After all, breasts don’t get faster with time! A paced feeding will ideally average 15-20 minutes in length, just like a nursing session.
Switching Sides
Babies who are fed at the breast have better binocular vision and symmetry of head/neck development. This is only because a parent who is nursing directly will switch sides! That aspect is easy enough to replicate. Most people hold the bottle with their dominant hand and it does take some practice to get comfortable using the other hand, but it really is just about practice. Giving bottles in a breastfeeding like position lets gravity help with this, too, by having gravity help hold the baby in place. Some people switch sides halfway through each feeding while others just alternate sides from one feeding to the next.
Minimize pacifier use
An exclusively at-breast fed baby will also get all non-nutritive sucking done at the breast. Babies will often look around, crawl around, and even walk around with a pacifier in their mouth. This frequently results in a delay in learning other skills for self-regulation and even speaking. A shape of pacifier that is simple, like the bottle nipple, helps. “Orthodontic” shaped pacifiers are much easier for a baby to passively hold onto, and are best avoided.
While some do start thumb sucking, a baby who has to be in the “boring” at-breast position for non-nutritive sucking is going to be much less likely to develop an oral fixation that causes orthodontic issues or have delays in speaking. It opens up their world (and half their face) for other forms of soothing! While it is important for babies to have non-nutritive sucking, pacifier use can be minimized by setting boundaries on when it is available. The most therapeutic use of a pacifier would be to only use it when a baby is being held. If they want to get down and play or crawl, the pacifier stays with the parent. Having the pacifier on a long necklace that the parent wears is an easy way to set this boundary. It also helps keep track of the paci! Many parents might also use it in the car or for sleep. There are many variations on boundaries for pacifier use. It’s most important to be thoughtful about it.
Ultimately, each family finds the right balance for themselves. Each of these things does not have to be all or nothing. They are ideas for rounding out the bottle feeding experience for both parents and babies so that some of the benefits of direct breastfeeding are maintained. It is incredibly important that parents have grace with themselves about which aspects will be a good fit for their family -and which will not. The nurturing act of feeding a baby has so much potential. It can be something that is a form of connection and developmental support for the entire first year, regardless of the delivery system. Parents should trust their instincts about what is right for their baby and their family, as a whole, adapting and evolving along the way. After all, every stage with a baby is a new adventure!
Jessica Altemara is an IBCLC in private practice since 2009. Her goal is to provide excellent, customized, connected care for breastfeeding families in the Triangle region of NC, including Raleigh, Durham, Chapel Hill, Cary, Hillsborough, and surrounding areas. Her practice focuses on meeting the needs of breastfed babies and toddlers who are (or were recently) tongue tied. Her personal and professional experience has led her to work to build an integrative practice utilizing the three pillar approach. Jessica also has a background in education that she utilizes to teach other professionals about optimizing outcomes for families dealing with tongue tie. The original Tongue Tie Doula, she is working to expand care to include a functional medicine mindset and bigger picture care plans.
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